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BUCK 2011 - Chapter 013


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BUCK 2011 - Chapter 013

  2. 2. MEDICAL CODING <ul><li>Transforms services/procedures/ supplies/drugs into __________ codes </li></ul><ul><li>Transforms diagnosis and procedures into ________ codes </li></ul>CPT/HCPCS ICD-9-CM
  3. 3. Levels of Service Codes <ul><li>Level I CPT—(Category 1: 99201-99607, Category III: 0017T-0259T) </li></ul><ul><li>Level II HCPCS, National Codes—(A0021-V5364) </li></ul><ul><li>Level III Local Codes—phased out due to HIPAA </li></ul>
  4. 4. Diagnosis Codes <ul><li>ICD-9-CM, Volumes 1 & 2 </li></ul><ul><li>International Classification of Diseases , 9th Ed., Clinical Modification </li></ul>
  5. 5. ICD-9-CM <ul><li>Classification ______ </li></ul><ul><li>Explains why service was provided </li></ul><ul><li>Changes diagnoses into _____ </li></ul><ul><li>Diabetes becomes ___ .XX (highest level of specificity) </li></ul>system 250 codes
  6. 6. Why Codes? <ul><li>Computers understand ________ </li></ul><ul><li>Specific descriptions attached to each code </li></ul>numbers
  7. 7. CPT <ul><li>Developed by the AMA in ____ </li></ul><ul><li>____ -digit codes </li></ul><ul><li>Updated in _________ for use January 1 </li></ul>Five 1966 November
  8. 8. Examples of Types of CPT Codes <ul><li>Medical </li></ul><ul><li>Surgical </li></ul><ul><li>Diagnostic services </li></ul><ul><li>Anesthesia, etc. </li></ul><ul><li>Category II and Category III codes—alpha numeric </li></ul><ul><ul><li>Category II = ___________ measuring </li></ul></ul><ul><ul><li>Category III = emerging __________ </li></ul></ul>performance technology
  9. 9. CPT Codes Allow For <ul><li>Communication that is both _______ and _______ </li></ul><ul><li>A mechanism to report a service not described by a specific CPT or Level II code </li></ul>effective efficient
  10. 10. Consider <ul><li>Renal endoscopy through nephrostomy or pyelotomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with endopyelotomy (includes cystoscopy, ureteroscopy, dilation of ureter and ureteral pelvic junction, and insertion of endopyelotomy stent) </li></ul><ul><li>OR 50575 </li></ul>
  11. 11. Codes Are <ul><li>Used to tell third-party payers about ________ /procedures provided </li></ul><ul><li>Often used as basis of _______ </li></ul>services payment
  12. 12. Incorrect Coding <ul><li>Results in providers being paid _____________ </li></ul><ul><ul><li>Either over or underpayment </li></ul></ul><ul><ul><li>Decreases cash flow </li></ul></ul><ul><ul><li>Liability risk </li></ul></ul>inappropriately
  13. 13. Codes Are Used By <ul><li>Clinics </li></ul><ul><li>Hospitals </li></ul><ul><li>Rehabilitation units </li></ul><ul><li>Ambulance services </li></ul><ul><li>Long-term care </li></ul><ul><li>Wherever __________ services are provided </li></ul>health care
  14. 14. Outpatient Services for Physicians <ul><li>Reported on insurance form </li></ul><ul><li>_________ = universal form </li></ul>CMS-1500
  15. 15. CMS-1500 Figure: 13.1
  16. 16. CPT Format <ul><li>Symbols in CPT </li></ul><ul><li>Used to convey __________ </li></ul><ul><li>________ , moderate (conscious) sedation included (full list in Appendix G, CPT) </li></ul><ul><ul><li>Example 45391, Colonoscopy with endoscopic ultrasound examination </li></ul></ul><ul><li>____________ , pending FDA approval (Appendix K, CPT) </li></ul><ul><ul><li>Example 90650, Human Papilloma virus (HPV) vaccine, types 16, 18, bivalent, 3 dose schedule, for intramuscular use </li></ul></ul>information Bullseye Lightning bolt
  17. 17. • Bullet = ____ Code <ul><li>Figure: 13.2 </li></ul><ul><li>Circle ( ○ ) = Reinstated or recycled code </li></ul>New Figure: 13.6
  18. 18. ▲ Triangle = _______ Code <ul><li>Figure: 13.3 </li></ul>Revised
  19. 19. ►◄ Right and Left ________ = Beginning and Ending of Text Change <ul><li>Figure: 13.4 </li></ul>Triangles
  20. 20. _____ = Add-On Code <ul><li>Figure: 13.5 </li></ul>+ Plus
  21. 21. Add-On Code <ul><li>(…Cont ’d) </li></ul><ul><li>Can only be used with another specific code </li></ul><ul><li>Never used _____ </li></ul><ul><li>No reduction for multiple services </li></ul><ul><li>Full list in Appendix _ of CPT </li></ul>alone D
  22. 22. =Circle With Line, <ul><li>CPT Appendix E contains a listing of - 51 exempt codes </li></ul><ul><li>Services typically exempt from multiple procedure reductions </li></ul>-51 Cannot Be Used With these Codes Figure: 13.7
  23. 23. Appendices of CPT <ul><li>Appendix A : ________ </li></ul><ul><li>Appendix B : Additions, ________ , Revisions </li></ul><ul><li>Appendix C : Clinical Examples, ___ Codes </li></ul><ul><li>Appendix D : _______ Codes </li></ul><ul><li>Appendix E : ___ Exempt Codes </li></ul><ul><li>Appendix F : ___ Exempt Codes </li></ul><ul><li>Appendix G : Include Moderate ( _________ ) Sedation </li></ul>Modifiers Deletions E/M Add-On -51 -63 Conscious (Cont ’d…)
  24. 24. Appendices of CPT <ul><li>(…Cont ’d) </li></ul><ul><li>Appendix H : Performance Measures, Category __ Codes, on website </li></ul><ul><li>Appendix I : Genetic Testing ________ </li></ul><ul><li>Appendix J : Electrodiagnostic Medicine Listing of _______ , _____ , and Mixed Nerves </li></ul><ul><li>Appendix K : Product Pending ____ Approval </li></ul><ul><li>Appendix L : ________ Families </li></ul><ul><li>Appendix M : Crosswalk to _______ CPT Codes </li></ul><ul><li>Appendix N : Summary of Resequenced CPT Codes </li></ul>II Modifiers Sensory Motor FDA Vascular Deleted
  25. 25. ___ CPT Sections (like chapters) <ul><li>Evaluation & Management (E/M) </li></ul><ul><li>Anesthesia </li></ul><ul><li>Surgery </li></ul><ul><li>Radiology </li></ul><ul><li>Pathology & Laboratory </li></ul><ul><li>Medicine </li></ul><ul><li>Category II Codes </li></ul><ul><li>Category III Codes </li></ul><ul><li>Appendices A-M </li></ul><ul><li>Index </li></ul>Six
  26. 26. Categorized By <ul><li>Sections </li></ul><ul><li>Subsections </li></ul><ul><li>Subheadings </li></ul><ul><li>Categories </li></ul>
  27. 27. Categorized By <ul><li>(…Cont ’d) </li></ul><ul><li>________ </li></ul><ul><ul><li>Knee or Shoulder </li></ul></ul><ul><li>_________ </li></ul><ul><ul><li>Incision or Excision </li></ul></ul><ul><li>_________ </li></ul><ul><ul><li>Fracture or Dislocation </li></ul></ul><ul><li>__________ </li></ul><ul><ul><li>Cast or Strap </li></ul></ul><ul><li>________________ </li></ul><ul><ul><li>Anterior Cranial Fossa or Middle Cranial Fossa </li></ul></ul>Anatomy Procedure Condition Description Surgical Approach
  28. 28. Categorized By, Example <ul><li>Figure: 13.9 </li></ul>(…Cont ’d)
  29. 29. Guidelines <ul><li>Section-specific information begins each section </li></ul>Figure: 13.10
  30. 30. Notes <ul><li>Must-reading located throughout the CPT </li></ul>Figure: 13.12
  31. 31. Two Types of Codes <ul><li>Stand-alone: ___ description </li></ul><ul><li>Indented: Dependent on _________ __________ </li></ul><ul><ul><li>Verbiage before the semicolon applies to all indented codes that follow </li></ul></ul>Full preceding stand-alone
  32. 32. Types of Codes, Example Figure: 13.14
  33. 33. Semicolon <ul><li>Indicates full description in ______________ </li></ul><ul><li>You must return to the stand-alone for full description </li></ul>preceding code
  34. 34. Modifiers Add Information <ul><li>CPT Modifier </li></ul><ul><li>Two digits </li></ul><ul><ul><li>62 Two surgeons performed a surgical procedure </li></ul></ul><ul><ul><li>Each surgeon applies his/her individual skill </li></ul></ul><ul><ul><li>Each surgeon bills the procedure with modifier -62 </li></ul></ul>
  35. 35. Level II HCPCS Modifiers <ul><li>“ -AS” Physician’s Assistant </li></ul><ul><li>“ -F1” Left hand, second digit </li></ul><ul><li>__ modifiers used on CPT or HCPCS </li></ul>All
  36. 36. Example of Modifier <ul><li>43820 Gastrojejunostomy </li></ul><ul><ul><li>-62 two surgeons </li></ul></ul><ul><ul><li>-43820-62 two surgeons performed a gastrojejunostomy </li></ul></ul><ul><ul><li>-62 modifier may be allowed based on payor Example: Medicare requires documentation of medical necessity </li></ul></ul>
  37. 37. Modifier on the CMS-1500 <ul><li>Modifiers are placed in 24D on CMS-1500 </li></ul>
  38. 38. Unlisted Services <ul><li>Codes ending in ____ = “no specific Category I or III code” </li></ul><ul><li>Used if ___________________ </li></ul><ul><li>____________ must accompany submission </li></ul>“ 99” no more specific code Special report
  39. 39. Special or Written Report Indicates: <ul><li>Nature </li></ul><ul><li>Extent </li></ul><ul><li>Need </li></ul><ul><li>Time </li></ul><ul><li>Effort </li></ul><ul><li>__________ Used </li></ul><ul><li>Photos and medical journal articles if relevant </li></ul>Equipment
  40. 40. Category I Codes <ul><li>Category _ codes (00100–99607) </li></ul><ul><ul><li>Approved by AMA and Food and Drug Administration </li></ul></ul><ul><ul><li>Proven clinical effectiveness (efficacy) </li></ul></ul>I
  41. 41. Category II Codes— Supplemental Tracking Codes <ul><li>Used for ___________ measurements </li></ul><ul><li>Codes collect data concerning quality of care and test(s) required </li></ul><ul><li>____________ and end in the letter “F” (1006F) </li></ul><ul><li>Location AMA Website </li></ul>performance Alphanumeric
  42. 42. Category III Codes— New Technology <ul><li>Temporary codes—up to _ years </li></ul><ul><li>Identify emerging technology, services, and procedures </li></ul><ul><li>Located after ________ section </li></ul><ul><li>Alphanumeric (0016T) </li></ul><ul><ul><li>May or may not receive future ________ I code status </li></ul></ul>5 Medicine Category
  43. 43. Category III Codes <ul><li>Category __ codes have not been approved and have no proven clinical effectiveness </li></ul><ul><li>Usage order </li></ul><ul><ul><li>Use ___________ code instead of unlisted code </li></ul></ul><ul><ul><li>Use unlisted code if no Category III code </li></ul></ul>III Category III
  44. 44. The Index! <ul><li>Used to locate service/procedure terms and codes </li></ul><ul><li>Speeds up code location </li></ul><ul><li>Like a dictionary </li></ul><ul><li>First entries and last entries </li></ul>
  45. 45. CPT Index <ul><li>Figure: 13.18 </li></ul>
  46. 46. Presentation of Codes in Index <ul><li>Single code: 38115 </li></ul><ul><li>Multiple codes: 26645, 26650 </li></ul><ul><li>- Note ______ </li></ul><ul><li>Range of codes: 22305-22325 </li></ul><ul><li>- Note ______ </li></ul>comma hyphen
  47. 47. Location Methods With Examples <ul><li>________________ : repair, excision </li></ul><ul><li>____________ : median nerve, elbow </li></ul><ul><li>__________________ : cleft lip, clot </li></ul><ul><li>________ : toe and interphalangeal joint </li></ul><ul><li>_______ : Jones procedure, Heller operation </li></ul><ul><li>___________ : ECG, PEEP (Pressure Breathing, Positive) </li></ul>Service/procedure Anatomic site Condition or disease Synonym Eponym Abbreviation
  48. 48. Always <ul><li>Reference index </li></ul><ul><li>Locate code in ___________ of CPT </li></ul><ul><li>Read the entire __________ and any _____ </li></ul>main portion description notes
  49. 49. “ See” in Index <ul><li>Cross-reference terms </li></ul><ul><ul><li>“ Look here for code” </li></ul></ul><ul><li>Index: Stem, Brain: See Brainstem </li></ul>
  50. 50. HCPCS <ul><li>Healthcare Common Procedure Coding System </li></ul><ul><li>Developed by Centers for Medicare and Medicaid Services ( ____ ) </li></ul><ul><ul><li>Formerly _____ </li></ul></ul><ul><li>HCPCS developed, ____ </li></ul><ul><li>CPT did not contain all codes necessary for Medicare services reporting </li></ul>CMS HCFA 1983
  51. 51. Levels of Codes <ul><li>Level I: ___ </li></ul><ul><li>Level II: _______ , also known as national codes </li></ul><ul><li>Level III: Local codes ( __________ ) due to HIPAA </li></ul>CPT HCPCS phased out
  52. 52. Level III, Local Codes <ul><li>Developed by Medicare carriers for use at local level </li></ul><ul><li>Varied by locale </li></ul><ul><li>Discontinued December 31, 2003 </li></ul><ul><ul><li>Some codes incorporated into HCPCS Level I and II </li></ul></ul>
  53. 53. Level II: _______ Codes <ul><li>Codes for wide variety of providers </li></ul><ul><ul><li>Physicians </li></ul></ul><ul><ul><li>Dentists </li></ul></ul><ul><ul><li>Orthodontists </li></ul></ul><ul><ul><li>Temporary codes for Medicare </li></ul></ul>National (Cont ’d…)
  54. 54. Level II: National Codes <ul><li>(…Cont ’d) </li></ul><ul><li>Codes for wide variety services </li></ul><ul><ul><li>Specific drugs </li></ul></ul><ul><ul><li>________________________ (DME) </li></ul></ul><ul><ul><li>Ambulance services </li></ul></ul>Durable medical equipment
  55. 55. HCPCS Gains Popularity <ul><li>Many payers require </li></ul><ul><li>Each year increased number of HCPCS codes </li></ul><ul><ul><li>J0585—Botox, per unit </li></ul></ul>
  56. 56. Format <ul><li>Begins with ____ , followed by four _____ </li></ul><ul><ul><li>Example: E0618, apnea monitor </li></ul></ul><ul><li>Each letter represents group of codes </li></ul><ul><ul><li>Example: “ _ ” codes used to report drugs and dosage </li></ul></ul>letter digits J
  57. 57. Temporary Codes <ul><li>Certain letters ( _ , K, _ , S, H, T) indicate temporary codes </li></ul><ul><ul><li>Example: K0006 heavy duty wheelchair </li></ul></ul><ul><li>Code books published every ______ </li></ul><ul><ul><li>But codes added, deleted, and revised throughout the year </li></ul></ul><ul><ul><li>Notified through carrier bulletins </li></ul></ul>G Q January
  58. 58. Coverage <ul><li>Just because item/service has HCPCS code does NOT mean service covered </li></ul><ul><ul><li>Example: </li></ul></ul><ul><ul><li>V5130, _______ __________ </li></ul></ul><ul><ul><li>Not covered under Medicare </li></ul></ul>From Cummings CW, Flint PW, Harker LA, Haughey BH, Richardson MA, Robbins KT, Schuller DE, Thomas JR, editors: Cummings Otolaryngology-Head & Neck Surgery, ed 4, Philadelphia, 2005, Mosby. binaural hearing aid
  59. 59. Where HCPCS Are Used <ul><li>_________ settings </li></ul><ul><ul><li>Including outpatient departments in hospital </li></ul></ul><ul><li>Level I and II used to report outpatient services to certain payers </li></ul>Outpatient
  60. 60. HCPCS Index <ul><li>Directs to specific codes </li></ul><ul><li>Do not code directly from index </li></ul><ul><li>Reference main portion text before assigning code </li></ul><ul><li>See Figure 13 – 22 in textbook </li></ul><ul><li>(Cont ’d…) </li></ul>
  61. 61. HCPCS Index <ul><li>Alphabetical order </li></ul><ul><li>(Cont ’d…) </li></ul>(…Cont ’d) Figure: 13.22 Modified from Buck CJ: 2011 HCPCS Level II Professional Edition, St. Louis, 2011, Saunders.
  62. 62. HCPCS Index <ul><li>Main text display </li></ul>(…Cont ’d) Figure: 13.27 Modified from Buck CJ: 2011 HCPCS Level II Professional Edition, St. Louis, 2011, Saunders.
  63. 63. HCPCS Modifiers <ul><li>___ and ______ modifiers used with both HCPCS and CPT codes </li></ul>Figure: 13.25 CPT HCPCS Modified from Buck CJ: 2011 HCPCS Level II Professional Edition, St. Louis, 2011, Saunders.
  64. 64. Anatomical Modifiers <ul><li>F1 Left hand, second digit </li></ul><ul><li>__ Left hand, third digit </li></ul><ul><li>F3 Left hand, fourth digit </li></ul><ul><li>F4 Left hand, fifth digit </li></ul><ul><li>FA Left hand, thumb </li></ul><ul><li>__ Right hand, thumb </li></ul><ul><li>F6 Right hand, second digit </li></ul><ul><li>F7 Right hand, third digit </li></ul><ul><li>__ Right hand, fourth digit </li></ul><ul><li>F9 Right hand, fifth digit </li></ul>F2 F5 F8
  65. 65. Often Used HCPCS Modifiers <ul><li>__ Left </li></ul><ul><li>__ Right </li></ul><ul><li>Example: </li></ul><ul><ul><ul><li>Right kidney biopsy, 50200-RT </li></ul></ul></ul><ul><ul><ul><li>Left kidney biopsy, 50200-LT </li></ul></ul></ul>LT RT
  66. 66. Ambulance Modifiers <ul><li>Origin and destination used in combination: </li></ul><ul><ul><li>First letter: _____ </li></ul></ul><ul><ul><li>Second letter: __________ </li></ul></ul><ul><ul><li>Example: </li></ul></ul><ul><ul><ul><li>R = Residence </li></ul></ul></ul><ul><ul><ul><li>H = Hospital </li></ul></ul></ul><ul><ul><ul><li>RH: origin (first letter) residence and destination (second letter) hospital </li></ul></ul></ul>Origin Destination
  67. 67. Table of Drugs <ul><li>Listed by generic name </li></ul>Modified from Buck CJ: 2011 HCPCS Level II Professional Edition, St. Louis, 2011, Saunders. Figure: 13.26
  68. 68. Durable Medical Equipment <ul><li>DME </li></ul><ul><li>Used with chronic disabling condition </li></ul><ul><li>Medicare and Medicaid pay for some DME items </li></ul><ul><li>Physician must attest to need using __________________ Necessity </li></ul>Certificate of Medical
  69. 69. Home Oxygen Therapy <ul><li>Medicare may also pay for oxygen with certain medical conditions </li></ul><ul><li>Physician must complete form (CMS- ___ ) attesting to medical necessity </li></ul>484